"In many hospitals, there are 6 to 8 patients per nurse, and 8 hours or more may pass between times when a patient's vital signs are taken," said lead researcher Michael Young, M.D., Assistant Professor of Medicine and Director of the Medical ICU at the University of Vermont/Fletcher Allen Health Care in Burlington. "Most hospitals lack explicit criteria to decide when a patient should be evaluated by a physician to determine whether the patient should be transferred to the ICU. We need validated standards that prompt urgent bedside evaluation of a patient 7 days a week, 24 hours a day. Timely physician bedside evaluation of hospitalized patients at risk for catastrophic deterioration could potentially prevent thousands of deaths each year."
Dr. Young and colleagues studied 47 patients at a teaching hospital who were transferred from a hospital ward to the medical/surgical ICU over five months. They determined when these 47 patients first met any of 11 pre-specified physiologic criteria, such as changes in breathing rate, blood pressure, heart rate and mental status. The researchers found that 48% of patients who were transferred to the ICU more than four hours after meeting one of the physiologic criteria either died or needed skilled care after hospital discharge, compared with 39% of those patients who were transferred in less than four hours. Patients who survived were transferred twice as quickly to the ICU than those that died.
"Our preliminary data suggests that once certain physiologic criteria are met such as a very low blood pressure or a deterioration in mental status, a patient should be urgently evaluated by a physician," Dr. Young said. "That does not mean that the patient necessarily needs to be transferred to the ICU--in fact 90% of patients who met one of these criteria in an earlier study we conducted in Utah did not come to the ICU – but they should be promptly evaluated."
He found that patients transferred to the ICU more than four hours vs. less than four hours after suffering a physiologic deterioration were 55% less likely to receive major medical interventions in the first six hours. "Timely medical interventions appear more likely to happen in patients transferred rapidly to the ICU compared with 'slow transfer' patients.
Our early data suggests that many interventions, such as mechanical ventilation and very large amounts of intravenous fluid administration (often needed in cases of severe infection) may be deferred until after patients are transferred to the ICU from the ward," Dr. Young said.
In the study he conducted in Utah, Dr. Young found that when a patient's nurse notified a physician about the patient's change in vital signs within two hours of the event, the patient was far more likely to be transferred to the ICU in less than four hours ('fast patients'). "In that study, the differences in death rates were huge--41% of 'slow transfer' patients died, compared with just 11% of 'fast transfer' patients," Dr. Young noted. "In our Utah study, a barrier to timely evaluation of patients appeared to be a communication gap between nurses and doctors. This gap likely delayed doctors coming to the bedside to re-evaluate patients."
Other related questions need further study, Dr. Young noted, such as, "Do treatments and outcomes differ for hospitalized patients who becomes sicker at night and on weekends versus during the day Monday through Friday? What is optimal frequency of vital signs? And does the nurse-to-patient ratio influence a nurse's decision to contact a physician when patients suffer physiologic deterioration?"